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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Changes to EnvisionConnect by CERS Integration Wizard Date run: 1/26/2016 <br /> Submitted on: 1/25/2016 1:54:53PM CERS ID: 10187427 <br /> Submitted by: Denise Pogue Email: kpogue@artelllc.net Facility ID in CERS: FA0019928 <br /> Information prior to CIW processing Information after CIW processing CERS <br /> OWNER INFORMATION (current EC database) (current submittal) field <br /> Number of Facilities for this Owner: 1 <br /> Owner ID OW0016351 <br /> Owner name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 111 <br /> Mailing address 840 S FAIRMONT AVE STE#1 840 S FAIRMONT AVE STE#1 113 <br /> LODI, CA 95240 LODI, CA 95240 114, 115, 116 <br /> Work phone 209-371-8700 209-371-8700 112 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019928 <br /> Facility name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 3 <br /> Site address 840 S FAIRMONT AVE STE 1 840 S FAIRMONT AVE STE 1 103 <br /> City LODI LODI 104 <br /> ZIP code 95240 95240 105 <br /> Facility phone 209-333-0905 (209) 333-0905 102 <br /> Facility mailing address 840 S FAIRMONTAVE STE#1 840 S FAIRMONTAVE STE#1 108a <br /> LODI, CA 95240 LODI, CA 95240 108b,1osc,load <br /> BILLING INFORMATION <br /> Contact name ENDOSCOPY CENTER OF LODI LLC ENDOSCOPY CENTER OF LODI LLC 140 <br /> Address 840 S FAIRMONTAVE STE#1 840 S FAIRMONTAVE STE#1 143 <br /> LODI, CA 95240 LODI, CA 95240 144, 145, 146 <br /> Contact phone 209-371-8700 209-371-8700 141 <br /> Contact email 142 <br /> Mail invoices to Account <br /> Program record ]-�I SQG HW [ ] LOG HW [ ] RCRAHW New PR#: ROSLlo7 3 <br /> created [ ] Tiered permit [ ] APSA [ ] CalARP [ ] UST New PE: '3`' <br /> Assigned to: \/E--L-y5D <br /> Please bill: [ ] full calendar year [ ] prorate this calendar year [ ] next calendar year [ ] exempt from billing <br /> Processed through CERS Integration Wizard by: fes_Date: <br /> Accounting: Reviewed by: (� Date: 1 /041Clerical: [ ] File ( ] Relabel file [ ] Create new file <br /> [ ] Acct billed [ ] Surcharge verified By: Date: <br /> ACTIVE PROGRAM RECORDS PRIOR TO PROCESSING THROUGH CIW <br /> Program Element and Description Record ID Employee name Status Reactivated Inactivated <br /> 1921 -HMBP-Regular-Primary Locatiop PRO530772 JAMIE DE LA ROSA Active [ ] [ ] <br /> 4530-LG QUANITY GENERATOR PRO536153 ALFONSO ARAMBULA Active ( ] [ ] <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FI PRO532119 not assigned Inactive [ ] [ ] <br />